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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206771
Report Date: 06/21/2022
Date Signed: 06/21/2022 10:10:48 AM

Document Has Been Signed on 06/21/2022 10:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SAILS APPLETREEFACILITY NUMBER:
157206771
ADMINISTRATOR:JACQUELINE D. TUCKERFACILITY TYPE:
735
ADDRESS:11611 SAN MINIATO AVETELEPHONE:
(661) 473-2337
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 5CENSUS: 4DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Jacqueline TuckerTIME COMPLETED:
10:23 AM
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On 6/21/2022, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Infection Control Inspection. LPA introduced self and allowed entrance by Direct Care Staff. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point, all staff and visitors enter through front door. All facility staff observed to be wearing face masks.

Facility appeared clean with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid, hand washing posters observed near sink, paper towels and hand soap available. Resident rooms toured, facility has all private rooms. All bedrooms observed to have required furnishing and lighting. Food supply observed to be adequate for residents in care. Medication observed to be locked and secured in office, all residents have a 30-day supply of medication available.
Fire extinguisher present with a service date of 4/22/22. Carbon monoxide and smoke detectors present and observed to be operational during today's inspection. Water temperature measured at 109 degrees F.

LPA received copies of LIC 500, LIC 610 and LIC 9020 during facility inspection. Administrator to submit copies of current Administrator Certificate to Department when received.

No deficiencies observed during today's inspection. Exit interview
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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